General Description
Under the direction of the Chief Government Affairs and Compliance Officer (CGACO), the Program Manager, Regulatory Readiness ensures that HPSM achieves and maintains compliance with the requirements and standards for its Medicare Advantage Dual-Eligible Special Needs Plan (DSNP). Serving as a central point of coordination within HPSM, the Program Manager, Regulatory Readiness maintains regular communication with internal and external stakeholders to assess and ensure adherence to Medicare standards, including, but not limited to, Medicare Final Rules and DHCS Policy Guides. The role is responsible for identifying gaps and barriers and developing mitigation strategies to proactively identify and resolve areas of risk.
Qualifications
The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

Education and Experience

• Bachelor’s degree in business administration, Health Care Management, Public Policy, or related field required; MBA, MPH, or MPP Preferred.
• Minimum three (3) years’ experience with project/program management experience required.
• Minimum three (3) years of managed care experience, preferably with Medicare/Medi-Cal.
• Experience with Medicare Advantage, DSNP, or NCQA for Medicare health plans preferred.
• Experience with quality improvement/process improvement techniques preferred.

Skills

• Advanced project management, program evaluation, and consulting skills.
• Intermediate continuous improvement or improvement science (Lean, Six Sigma, etc.) skills.
• Intermediate change management and process redesign skills.
• Advanced relationship building and interpersonal communication skills.
• Intermediate financial/quantitative acumen skills.
• Intermediate Microsoft Office Suite skills (e.g., Outlook, Teams, Word, Excel, and PowerPoint).
• Intermediate experience using project management tools.

Knowledge

• Extensive knowledge of accrediting/regulatory body requirements.
• Extensive knowledge of organizational behavior strategies and results-oriented leadership.
• Working knowledge of change management and process improvement principles.
• Extensive knowledge of project management practices and methodologies.

Abilities

• Demonstrated ability to lead through influence rather than authority.
• Demonstrated ability to think critically and make informed decisions.
• Ability to work cooperatively with others and support team decisions.
• Ability to communicate effectively, both verbally and in writing.
• Ability to adapt to changes in priorities or requirements.

Licensure/Certifications

• Not applicable.

Driving

• Not applicable.

Duties & Responsibilities
Essential Functions

Medicare Compliance Oversight

• Function as the Medicare subject matter expert (SME) for the organization.
• Manage all aspects of Medicare readiness, including gap analysis, mock auditing, and performance monitoring.
• Schedule and oversee mock file reviews and surveys to assess Medicare readiness.
• Develop and maintain a detailed project plan to assess compliance with Medicare standards.

Stakeholder Support and Education

• Partner with internal stakeholders to ensure understanding of Medicare standards, timelines, and best practices.
• Assist in developing and tracking implementation plans related to Medicare compliance.
• Identify opportunities for innovation and improvement within business units.
• Lead reflection process to assess readiness strengths and opportunities for the coming year.

Risk Mitigation and Strategic Advisory

• Identify and evaluate risks to Medicare readiness. Develops mitigation strategies in consultation with the Chief Government Affairs and Compliance Officer.
• Act as an internal consultant on integrating Medicare standards into operations, project timelines, and reporting.
• Provide technical assistance and best practices to stakeholders per industry insights.
• Leverage external relationships with sibling plans and consultants to inform internal strategies.

Cross-Functional Collaboration and Leadership

• Collaborate with the Compliance Department, Policy Implementation Unit, and NCQA Program Manager to align efforts.
• Find and capitalize on synergies between Medicare and non-Medicare compliance work.
• Contribute to project teams by assigning, monitoring, and guiding the work of team members.

Secondary Functions

• Serve as the Compliance liaison to broader organizational initiatives and projects as needed.
• Adhere to work performance norms and attendance expectations.
• Perform other duties as assigned.

Please refer the Job description for details